Robert T. Sataloff and Mary J. Hawkshaw

The symptom of hoarseness (coarse, scratchy sound) is caused by abnormalities of the vibratory margin of the vocal fold that cause turbulent airflow and acoustic perturbations. Hoarseness can be chronic or acute, persistent or intermittent. It can be associated with other symptoms, including postnasal drip, throat tickle, throat clearing, globus sensation, cough, fever, voice breaks, inability to project voice, voice fatigue, pain (throat, neck, or referred to ear), dysphagia, and weight loss. Hoarseness should be differentiated from other voice complaints that are often incorrectly described as hoarseness. The most common of these include breathiness, voice fatigue, volume disturbance, prolonged warm-up time, and tickling or choking during speech or singing.

Breathiness is caused by anything that interferes with glottal closure (masses, paralysis, neuromuscular weakness, cricoarytenoid joint dysfunction, and other abnormalities) and permits excessive air escape during phonation. Voice fatigue is the inability to continue to phonate for extended periods of time without change in voice quality. It may be caused by problems such as voice abuse or misuse (muscle tension dysphonia), generalized fatigue, neurological disorders (such as myasthenia gravis, or mild vocal fold paresis with hyperfunctional compensation). Volume disturbance is the inability to speak or sing loudly or to phonate softly. If not due to intrinsic limitations of the voice, the most common causes are technical errors in voice production. However, hormonal changes, aging, superior laryngeal nerve paresis, and other etiologies may be causal. Prolonged warm-up time is reported most commonly among singers. Normally, only 10 to 20 minutes are required for voice warm-up, even in the morning. The most common cause of prolonged warm-up time is laryngopharyngeal reflux. Tickling or choking during speech or singing may be caused by voice abuse, but it may also be a symptom of vibratory margin pathology. Odynophonia (pain while vocalizing) is most commonly due to muscle tension dysphonia. However, less common structural problems must be ruled out, including infection, laryngopharyngeal reflux, some laryngeal granulomas (although most are painless), laryngeal joint arthritis, and malignancy.

True hoarseness is most commonly caused by inflammation, edema, growths (benign and malignant), or vocal fold scarring.

Sudden onset hoarseness/voice change can be caused by infectious laryngitis, vocal fold hemorrhage, mucosal tear, and more serious problems, including neoplasm (onset of which may be sudden or gradual).